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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601425
Report Date: 08/17/2022
Date Signed: 08/17/2022 01:25:57 PM


Document Has Been Signed on 08/17/2022 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CRUSE HOUSE ALOHAFACILITY NUMBER:
075601425
ADMINISTRATOR:REYES, VIRGIL T.FACILITY TYPE:
740
ADDRESS:1850 MARINA COURTTELEPHONE:
(925) 338-2056
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 5DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Michael Bryan Manarang, CaregiverTIME COMPLETED:
01:45 PM
NARRATIVE
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On 08/17/2022 at 10:30 am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver, Michael Bryan Manarang and explained the purpose of the visit. Administrator Virgil Reyes arrived at approximately 11:00am.

Upon entry, LPA temperature was checked. LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and signs and symptoms of COVID-19 posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters.

During record review, LPA observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation.

The following deficiencies were observed during the visit:

-At 10:55am, LPA observed a unlocked medication cabinet.
-At 10:58am, LPA observed a bedroom located in the garage, that is not on facility sketch.
-At 10:59am, LPA observed a dresser, Santa figure, boxes, table, 2 microwaves, file cabinet, chairs, wood planks, paint, grout, located in the side yard.
-At 11:03am, LPA observed a window, missing wood plank on the fence, wood boards, located in the backyard.

Continued on LIC809C.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CRUSE HOUSE ALOHA
FACILITY NUMBER: 075601425
VISIT DATE: 08/17/2022
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Continued from LIC809.


The following forms are to be updated and submitted to CCLD by 8/24/2022

-LIC500 Personnel Report

-LIC308 Designation of Administrative Responsibility

-LIC610E Emergency Disaster Plan

-An updated copy of Administrator certificate

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.



Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/17/2022 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: CRUSE HOUSE ALOHA
FACILITY NUMBER: 075601425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having the medication cabinet unlocked and cleaning supplies such as Lysol, multipurpose disinfectant and febreze air freshener accessible to residents in care which poses an immediate health and safety to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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Administrator agreed to meet with staff about the importance of keeping the medication and clean supplies locked at all times. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/17/2022 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: CRUSE HOUSE ALOHA
FACILITY NUMBER: 075601425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation 87303(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a dresser, boxes, table, 2 microwaves, file cabinet, chairs, wood planks, paint, grout, and a window and broken plank on the fence located in the back and side yard which poses a potential health and safety risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Administrator agreed to haul away the dresser, boxes, table, 2 microwaves, file cabinet, chairs, wood planks, paint, grout, the window and repair the broken plank in the backyard. Administrator will provide photo copies to CCLD no later then the POC date.
Type B
Section Cited
CCR
87305(a)
87305 (a) Alterations to Existing Building or New Facilities

(a) Prior to construction or alterations, all facilities shall obtain a building permit.
POC: Administrator will submit approved permit from the local county department along with a new facility sketch to CCL no later than the POC date.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by building a bedroom in the garage which poses a potential health and safety to persons in care.
POC Due Date: 09/19/2022
Plan of Correction
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 Administrator agreed to submit an approved permit from the local county department along with a new facility sketch to CCL no later than the POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4